MADINA ENDOVASCULAR WORKSHOP 01

Information about MADINA ENDOVASCULAR WORKSHOP 01

Published on September 25, 2014

Author: MOHAMEDOMAR

Source: authorstream.com

Content

(1) Basic endovascular tools (Wires – Catheters – Balloons – Stents): (1) Basic endovascular tools (Wires – Catheters – Balloons – Stents) Mr. Mohamed Omar Elfarok , M.sc, FRCSENG,FRCSED, IME What to do you need to start : What to do you need to start Radiology equipment . Drugs Team Endovascular tools Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions ! .Radiology Equipment Fluoroscopy (continuous / pulsed) High frame rate (min 12 f/ sec) Digital subtraction Road mapping Maximum opacification Cine angiography Bolus chasing Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Radiology Equipment Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Radiology Equipment (Optional) Automatic injector Anesthesia machine Invasive pressure monitor Resuscitation trolley Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions 2. Drugs Heparin Protamine Nitroglycerine Prostavasin TPA Atropine Resuscitation trolley Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions 3.Team Nurse Radiology technician Invasive pressure technician Anesthesiologist Neurologist Nephrologist Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions 4. Endovascular tools Occlusive arterial disease Vena cava filters Thrombolysis Aneurysmal disease AV malformations / embolization Chronic venous occlusions Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Endovascular tools Needles Sheath / guiding catheters Wires Diagnostic catheters Balloon catheters Stents Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Needles Type Seldinger Single wall puncture Doppler tip Pulse view needle by Angiodynamics Size 18g (0.038 wire) 21g (0.018 wire) Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Sheaths Purpose: avoid trauma to the artery at the site of entry Choice: the smallest diameter to accept the largest tool to be used Length: 11cm Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Guiding catheters Purpose: Support the equipment to the site of lesion Allow delivery of contrast at the site of intervention Choice: Size: the smallest to accept tools Length & shape: procedure specific Catheters : Catheters Guiding catheters shapes : Guiding catheters shapes Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Guiding Sheaths Purpose: Same as guiding catheters with wider inner diameter Choice: Size: the smallest to accept tools Length & shape: procedure specific Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Wires Purpose : Lead the catheter to the site of intervention Choice: Diameter: 0.035 or 0.014 Length: 150cm or 260cm Tip shape: Straight or J or angled or movable Coating: Normal or Hydrophilic Strength: Normal or stiff How important is GW ?: How important is GW ? No GW = no intervention The choices of GW selections : The choices of GW selections Very personal No fixed hard rules mostly Only logic , experience and word of mouth What does the GW do ?: What does the GW do ? Access vessel Change Anatomy of a vessel Cross lesion Device support GW properties :: GW properties : Torque Tip control Trackability Steering Tip formability Kink resistance Radiopacity - visibility Tactile feedback Conformability - Straightening Tip Prolapsing Flexibility Lubricity Specification of GW: Specification of GW Diameter : 0.014 , 0.038 inches Length : 150 cm 300 cm Tip shape : straight , angled , J shaped ,others Coating : Hydrophilic , Hydrophobic Stiffness : soft , stiff , super-stiff , others Special features Component of a GW : Component of a GW GW Material : GW Material Stainless Steel • Nitinol Strong Elastic/ More Flexible Less Flexible Does not retain a shape when bent Retain tip shape Minimized kinking Better torque ability Less torqueability Greater tactile feedback Less tactile feedback More susceptible to kinking GW Core : GW Core Taper = reduces the diameter of the core Grind = the constant diameter of the core (area between the tapers) Tapers / Grinds describe the change in the wire diameter over a specific length Importance of Core design: Importance of Core design Abrupt transitions may result in difficulty accessing acute angles Gradual transitions, provide less prolapse and improves ability to follow itself into acute bends Coating : Coating Hydrophilic (“Water Loving”…Attracts water) - Coating that is very lubricious and slippery when it bonds -with water molecules . It Promotes crossability . Hydrophobic (“Water Hating”…Repels water) Usually a clear silicone coating on the working end of the wire . It Promotes tactile feel. Opposing features : Opposing features Device support Distal Trackability Lesion crossing Non-Traumatizing Tip trackability Tip Prolapsability Tip formability Tip Shape Retention How to chose your GW ?: How to chose your GW ? Anatomy Vessel angulation , Tortuosity , Bifurcation , type Chronic Total Occlusion Lesion Characteristics Location , Ostial , Bend , Bifurcation, Distal Morphology , Length - long, diffuse , Calcific , Highly stenosed Device Strategy New generation of wires : New generation of wires There is wires and there CTO wires A totally different group of wires Seldinger technique : Seldinger technique Anatomical mistake : Anatomical mistake Arterial access below skin crease : Arterial access below skin crease This is what happened : This is what happened CTO Pathology: CTO Pathology GW speaks : GW speaks Which wire and when ?: Which wire and when ? Dr. Sudhir Rathore MD , MRCP (UK) TCT 2009 Wire Shaping : Wire Shaping Dr. Sudhir Rathore MD , MRCP (UK) TCT 2009 Development of CTO wires : Development of CTO wires Development of wiring techniques : Development of wiring techniques Wire crossing CTO : Wire crossing CTO GW covers and coating : GW covers and coating Parallel wire technique: Parallel wire technique How to stay out of trouble : How to stay out of trouble Go slow • Schedule procedure when you have enough time to do the case Two hand technique Multiple angiographic projections Think about what you are seeing Don’t be afraid to stop and bring the patient back another day GW operator technique: GW operator technique Penetration Drilling Sliding Drilling technique : Drilling technique Short tip curve (~ 2mm) at 45-60 deg sometimes a proximal secondary curve Rapid rotational tip motion with gentle forward probing Start with moderate stiffness tips and stepwise increases in tip stiffness Premium on tactile responses Penetration technique: Penetration technique Similar tip shape and curves as drilling technique Sometimes called “controlled” drilling Minimal rotational tip motion with more aggressive forward probing Tip stiffness should penetrate even heavily calcified entry cap (9-12 gms and tapered) Reduced tactile responsiveness Sliding technique : Sliding technique Longer and shallower tip shapes and no secondary bends Simultaneous tip rotation and probing Almost no tactile response Takes advantage of reduced guidewire surface friction – requires polymer cover My selection of wires : My selection of wires Aorto -iliac = 0.035 platform Tibial = 0.14 platform SFA = 0.14 platform Aorto -iliac stenosis or occlusion : (1)Terumo curved –(2) Amplatz stiff (3) Road runner SFA stenosis : (1)Terumo ,or Zip ,or Acquire or H2O (2) V18 control (3) CTO wire Tibial wires : Tibial wires Stabilizer plus PT2 or Nitrix V18 Control Skipper deep Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Diagnostic catheters Purpose: Deliver contrast to site of lesion Deliver wire across a lesion Choice: Diameter: 5F Length: 60cm or 100cm or 130cm Tip Shape: procedure specific Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Diagnostic Catheters Tip Shape Aortography: Pigtail, Racket, Flush Hallow Aortic cross over: Hook, Renal Curve, Omni Flush Selective renal: Renal Curve, Renal Double Curve, Shepherd Hook Selective Visceral: Shepherd Hook, Omni Selective Carotid Subclavian: Head Hunter, Simmons Interventions: Multipurpose, Bernestein Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Balloon Catheters Purpose: Dilate stenotic lesions Choice: Balloon diameter Balloon length Shaft diameter / length Monorail / over-the-wire Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Stents Purpose: support vessel wall To prevent recoil after balloon To treat dissections To obtain wider lumen Basic Equipment for Peripheral Interventions: Basic Equipment for Peripheral Interventions Choice of Stent Type Self expandable: all except rigid osteal lesions Balloon expandable: osteal lesions in the trunk Diameter Self exp: 1-2mm > artery Balloon exp: same as artery Length Should cover the lesion completely Shaft Length: to reach the lesion ALWAYS BEGIN YOUR TRAINING AND YOUR SINGLE PROCEDURE WITH A GOOD QUALITY ANGIO: ALWAYS BEGIN YOUR TRAINING AND YOUR SINGLE PROCEDURE WITH A GOOD QUALITY ANGIO MINIMIZE RADIATION RISK: MINIMIZE RADIATION RISK 2 MONTHS AFTER PROCEDURE 6 MONTHS AFTER PROCEDURE 2 YEARS AFTER PROCEDURE PowerPoint Presentation: Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 COMMON ACCESS SITES FOR PERIPHERAL=FOR CORONARY PowerPoint Presentation: Garcia et al, Catheter Cardiovasc Interv 2009;74:27-36 LESS COMMON ACCESS SITES FOR PERIPHERAL≠FOR CORONARY PowerPoint Presentation: DEVICE TYPES ARE ALSO BROADLY SIMILAR Sheaths Shuttle sheaths Guidewires Balloons Stents Filters Thrombectomy catheters PowerPoint Presentation: BUT DEVICE SIZES AND FEATURES ARE VERY DIFFERENT! Sheaths (3-9 Fr) Shuttle sheaths (30-90 cm) Guidewires (0.014”, 0.018”, 0.035”) Balloons (1.25-15.0 mm) Stents (balloon-, self-expandable) Filters Thrombectomy catheters (4-6 Fr) PowerPoint Presentation: 2.0-4.0 5.0-7.0 4.0-7.0 4.0-6.0 6.0-9.0 5.0-9.0 5.0-7.0 7.0-10.0 6.0-8.0 2.0-4.0 5.0-7.0 3.0-5.0 SIZE MATTERS! IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB PTA: IMPORTANCE OF SUBINTIMAL ANGIOPLASTY FOR LOWER-LIMB PTA TAKE HOME MESSAGES: TAKE HOME MESSAGES Peripheral intervention skills must be mastered by all vascular surgeons Motivated interventionists can pursue further improvements by focusing on district-specific indications, anatomy, and devices No other specialist beats an experienced vascular surgeons in peripheral interventions and vascular procedures Thank you for your attention For any correspondence: [email protected] For these and further slides on these www.authorstream.com/ mohamed omar : Thank you for your attention For any correspondence: [email protected] For these and further slides on these www.authorstream.com/ mohamed omar PowerPoint Presentation: Thank You

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